Encyclopedia of

Stage Theory

The stage theory of dying was first proposed by the Swiss-American
psychiatrist, Elisabeth Kübler-Ross in her book,
On Death and Dying
(1969), is perhaps the single theoretical model that is best known to the
general public in the entire field of studies about death and dying
(thanatology). In its simplest form, this theory claims that dying people
will proceed through five stages: denial, anger, bargaining, depression,
and acceptance. More broadly, the theory maintains that other individuals
who are drawn into a dying person's experiences, such as family
members, friends, professional care providers, and volunteer helpers, may
also experience similar "stages of adjustment."

Origins of the Theory

Kübler-Ross explained in her book that she was a new faculty member
in psychiatry at a Chicago-area teaching hospital in the fall of 1965 when
four theological students seeking assistance with a student project
approached her. They had been assigned to write about a "crisis in
human life" and had chosen to examine death as "the biggest
crisis people had to face" (p. 21). In order to tackle this topic,
she agreed to help them gain access to and interview some dying patients.
According to Kübler-Ross, she encountered unexpected resistance from
the physicians and others who were responsible for the patients whom she
and her students wanted to interview: "These doctors were both very
defensive when it came to talking about death and dying and also
protective of their patients in order to avoid a traumatic experience with
a yet unknown faculty member who had just joined their ranks. It suddenly
seemed that there were no dying patients in this huge hospital" (p.
23).

Eventually, however, some suitable patients were found, and
Kübler-Ross developed a procedure whereby she would approach likely
candidates, secure their permission, and then interview them about their
experiences, while the students and others who came to observe would do so
from behind a one-way glass mirror. Following the interviews and the
return of the patients to their rooms, the group would discuss the
patients' responses and their own reactions.

On Death and Dying
is based on interviews with approximately 200 adult patients during a
period of less than three years. Examples from the interviews, along with
the clinical impressions and the theoretical model that Kübler-Ross
formed from these experiences, were subsequently reported in her book.

Stage Theory of Dying Examined

The theoretical model that Kübler-Ross developed from her interviews
postulated that with adequate time and support, dying persons experience
or work through five stages, including
denial,
often expressed as "No, not me, it cannot be true," is
described as an individual's unwillingness to acknowledge or broad
rejection of the fact that he or she is actually dying;
anger,
typically expressed as "Why me?," is a protest
acknowledging at least in some degree that the individual is dying but
simultaneously objecting or complaining that it is not fair or right that
it should be happening;
bargaining,
often expressed as "Yes me, but ...,"is less outraged and
more resigned to death while focusing (whether realistically or
unrealistically) on what might be done to postpone death or to have it
occur at a time or in ways that are more acceptable to the individual;
depression,
which involves a great sense of loss and which can take the form of
"reactive depression" (responding to losses the individual
has already experienced) or "preparatory depression"
(emphasizing impending losses, including the anticipated loss of all love
objects); and
acceptance,
described as "almost void of feelings" (p. 113), a
"final stage when the end is more promising or there is not enough
strength left to live" (p. 176).

A valuable addition to this five-stage theory, which is often overlooked,
is the observation that "the one thing that usually persists
through all these stages is hope" (p. 138) and the comment
that "it is this hope that should always be maintained whether we
can agree with the form or not" (p. 265).

Understanding Stage Theory of Dying

Kübler-Ross sought to address a dehumanization and depersonalization
that dominated the experiences of the dying persons with whom she came
into contact. She believed that dying was often a lonely, impersonal
experience for such persons, and thus an unnecessarily difficult burden
for them to bear. In fact, Kübler-Ross found that most of her
patients feared dying even more than death itself. For those who were
isolated in their dying and who felt unable to help themselves or to find
reasons to be hopeful, Kübler-Ross offered them a constructive
opportunity by asking them to help teach others about their experiences.
She was especially concerned that dying persons should share their
experiences with and become teachers to their professional caregivers and
their family members. At the same time, she asked others not to be
judgmental about the reactions dying persons have to their experiences,
but to try to enter into their perspectives and understand the origins of
those reactions.

The theory that resulted was essentially an effort "to categorize
crudely the many experiences that patients have when they are faced with
the sudden awareness of their own finality" (p. 29). The
"stages" within that theory were themselves understood by
Kübler-Ross as "reactions," "defenses" or
"defense mechanisms," "coping mechanisms," and
"adaptations and defenses." At one point, Kübler-Ross
wrote that these stages "will last for different periods of time
and will replace each other or exist at times side by side" (p.
138), while in another place she stated, "these stages do not
replace each other but can exist next to each other and overlap at
times" (p. 263). The stages are, in other words, a fairly loose
collection of psychosocial reactions to experiences associated with dying.
As such, they remind us that dying is a human process, not merely a series
of biological events. Also as such, they are not confined solely to dying
persons, but may be experienced by others who enter into the worlds of
those who are dying.

As initially proposed, the five stages in this theory were described in
very broad terms. Denial and acceptance, for example, were presented as
essentially mirror opposites, with the other three stages functioning
mainly as transitional reactions experienced while moving from denial to
acceptance. Both denial and acceptance were formulated in ways that
permitted them to apply to a spectrum of reactions: from a complete
rejection of one's status as an ill or seriously ill person to an
unwillingness to admit that one is dying or that one's death is
more or less imminent; and from acknowledgement, resignation, and
acquiescence to welcoming.

Of denial, Kübler-Ross wrote, "Denial, at least partial
denial, is used by almost all patients, not only during the first stages
of illness or following confrontation, but also later on from time to
time" (p. 39). More importantly, she added this further comment
about denial: "I regard it [as] a healthy way of dealing with the
uncomfortable and painful situation with which some of these patients have
to live for a long time. Denial functions as a buffer after unexpected
shocking news, allows the patient to collect himself and, with time,
mobilize other, less radical defenses" (p. 39). Not everyone who
took up this theory viewed denial in this constructive way.

Like denial and acceptance, anger, bargaining, and depression as the other
stages in this theory were said to vary in their intensity, character, and
focus. Individuals will differ, for example, in whether or not they
experience anger, what arouses their anger, the object(s) on which it
fixes, its degree, whether it is rational or irrational, and how it is
expressed. One troubling feature of anger is that it is said to be
"displaced in all directions and projected onto the environment at
times almost at random" (p. 50).

As for bargaining, this reaction seems to reflect a view that one can
postpone death or manipulate one's experiences of dying usually
through more or less explicit promises involving a prize and some
deadline: "I will faithfully follow the prescribed regimen you
prescribe, if it will only ward off my death"; "I will pray
each day, if you will preserve me from this awful fate"; "I
need to stay alive until my son is married." Promises are usually
addressed to presumed authorities, such as God or a physician, but
Kübler-Ross noted, "none of our patients have 'kept
their promise'" (p. 84).

Criticisms of the Stage Theory of Dying

There are essentially three distinct types of criticisms that have been
raised against the stage theory of dying. First, some commentators have
noted
that empirical research has provided no support for this model.
Kübler-Ross herself offered nothing beyond the authority of her
clinical impressions and illustrations from selected examples to sustain
this theory in its initial appearance. Since the publication of her book
in 1969, she has advanced no further evidence on its behalf, although she
has continued to speak of it enthusiastically and unhesitatingly as if its
reliability were obvious. More significantly, there has been no
independent confirmation of the validity or reliability of the theory, and
the limited empirical research that is available does not confirm her
model.

Second, the five sets of psychosocial reactions that are at the heart of
this theory can be criticized as overly broad in their formulation,
potentially misleading in at least one instance, insufficient to reflect
the full range of human reactions to death and dying, and inadequately
grounded for the broad ways in which they have been used. The expansive
way in which these five reactions are formulated has already been noted.
Kübler-Ross did not, of course, invent these five reaction patterns;
her inspiration was to apply them individually to the human experiences of
dying and facing death, and to link them together as part of a larger
theoretical schema. Among its peers, the trait of depression seems most
curious as an element in a healthy, normative process of reacting to
dying— unless it really means "sadness"—since
clinical depression is a psychiatric diagnosis of illness. Moreover, just
as Kübler-Ross seems sometimes to acknowledge that a particular
individual need not experience all five of these reactions, so one need
not believe there are only five ways in which to react to dying and death.
Finally, Kübler-Ross has applied this theory to children and to
bereavement in ways that are not warranted by its original foundations in
interviews with dying adults.

Third, the theory can be criticized for linking its five reaction patterns
together as stages in a larger process. To a certain extent
Kübler-Ross seems to have agreed with this point since she argued for
fluidity, give and take, the possibility of experiencing more than one of
these reactions simultaneously, and an ability to jump around from one
"stage" to another. If that is true, then this is not really
a theory of stages, which would require a linear progression and
regression akin to the steps on a ladder or the calibrations on a
thermometer or a hydraulic depth gauge. In short, the language of
"stages" may simply be too restrictive and overly specific
for what essentially appear to be a cluster of different psychodynamic
reactions to a particular type of life experience.

This last point is particularly important because if this theory has been
misused in some ways, its most unfortunate mishandling has come from those
who tell dying persons that they have already experienced one of the five
stages and should now "move on" to another, or from those
who have become frustrated and complain about individuals whom they view
as "stuck" in the dying process. When coupled with the
limits of five categories of reaction to dying, this schematic approach
tends to suppress the individuality of dying persons (and others) by
coercing them into a rigid, preestablished framework in which they are
expected to live out an agenda imposed on them at the end of their lives.
That is particularly ironic and unfortunate since Kübler-Ross set out
to argue that dying persons are mistreated when they are objectified and
dealt with in stereotypical ways. As she insisted, "a patient has a
right to die in peace and dignity. He should not be used to fulfill our
own needs when his own wishes are in opposition to ours" (p. 177).

One serious evaluation of this stage theory of dying by Robert Kastenbaum
raised the following points:

• The existence of these stages as such has not been
demonstrated.

• No evidence has been presented that people actually do move
from stage one through stage five.

• The limitations of the method have not been acknowledged.

• The line is blurred between description and prescription.

• The totality of the person's life is neglected in favor
of the supposed stages of dying.

• The resources, pressures, and characteristics of the immediate
environment, which can make a tremendous difference, are not taken into
account.

As a result, what has appeared to be widespread acclaim for this theory in
the popular arena and in certain professional quarters contrasts with
sharp criticism from scholars and those who work with dying persons.

What Can Be Learned from Stage Theory of Dying?

Charles Corr has suggested that there are at least three important lessons
to be learned from the stage theory of dying. The first lesson is that
those who are coping with dying are living human beings who will react in
their own individual ways to the unique challenges that confront them and
who may have unfinished needs that they want to address. The second lesson
is that others cannot be or become effective providers of care unless they
listen actively to those who are coping with dying and work with them to
determine the psychosocial processes and needs of such persons. And the
third lesson, a point that Kübler-Ross always stressed, is that all
individuals need to learn from those who are dying and coping with dying
in order to come to know themselves better as limited, vulnerable, finite,
and mortal, but also as resilient, adaptable, interdependent, and worthy
of love.

Reflecting at least in part on the stage theory of dying, some writers
have called for broader task-based or contextual theories of dying that
would strive to offer more respect for the individuality and complexities
of the many different ways in which persons live out their experiences of
dying and of coping with dying. Various contributions have been made
toward developing such broader theoretical frameworks, some emerging from
lessons learned in reflecting on the stage theory of dying, but no final
theory has yet been developed.

Corr, Charles A., Kenneth J. Doka, and Robert Kastenbaum. "Dying
and Its Interpreters: A Review of Selected Literature and Some Comments on
the State of the Field."
Omega: The Journal of Death and Dying
39 (1999):239–259.